In 2000, Copic Insurance Company reported that 70% of its claims involved medical record documentation issues. Many of these claims were indefensible, and could have been mitigated with solid documentation. Quality of care and cost-effectiveness also take priority.

There are three basic reasons for good medical record documentation: quality, cost and risk. Maintaining complete medical records contributes to improved patient care and health outcomes. It is the venue by which physicians meet the requirements of hospitals, payers and governing agencies. Thorough documentation can provide proof of the visit's complexity, thereby increasing the likelihood that payer reimbursement will be reflective of the care provided. Finally, without appropriate medical record keeping physicians will not be able to prove what occurred in the course of a patient visit, leaving themselves vulnerable to malpractice claims.

The following list is provided to help you get on the road to good medical record documentation.

* Write legibly;
* Document everything pertinent to the patient's care, including phone calls and after-hours calls;
* Include dates and signatures on all entries, reports, phone calls, and no shows;
* Use the SOAP (Subjective, Objective, Assessment, and Plan) format or equivalent in the progress notes;
* Document patient education and follow-up   
* Include and maintain updated chronic problem lists, allergy lists, medication lists, flow sheets (mandatory and optional), immunization charts, and growth charts (for pediatrics);
* Include lab reports, x-rays, special evaluations, consults, hospital records (including ER), and old medical records; and
* Keep the chart organized!

The Center for Personalized Education for Physicians (CPEP) offers "The Patient Care Documentation Seminar....How to Write Yourself Out of A Lawsuit" as a CME resource. This seminar is held four times per year, is co-sponsored by the Colorado Foundation for Medical Care and COPIC Companies, and offers up to 3 Experience Rating System (ERS) points and up to 11 CME credits. For more information, please contact: Megan Barnhurst, M.S. (303) 750-7150, mbarnhurst@cpepdoc.org